Acute abdomen 606

    Acute kidney injury 298

    Addisonian crisis 836

    Anaphylaxis 794

    Aneurysm, abdominal aortic 654

    intracranialextradural 78, 482

    gastrointestinal 256, 820

    rectal 629

    variceal 257, 820

    Antidotes, poisoning 842

    Arrhythmias, broad complex 128, 804

    narrow complex, SVT 126, 806

    Asthma 810

    Asystole 895

    Atrial ? utter? brillation

    Bacterial shock 790

    Blast injury 851

    Bradycardia 124

    Burns 846

    Cardiac arrest 894 (Fig A3)

    Cardiogenic tamponade 802

    Cardioversion, DC 770

    Central line insertion (CVP line) 774

    Cerebral oedema 830

    Chest drain 766

    Coma 786

    Cricothyrotomy 772

    Cyanosis 186¨C9

    Cut-down 761

    De? brillation 770, 894 (Fig A3)

    Diabetes emergencies 832¨C4

    Disseminated intravascular coagulopathy

    (DIC) 352

    Disaster, major 850

    Encephalitis 824

    Epilepsy, status 826

    Extradural haemorrhage 482

    Fluids, IV 666, 790

    Haematemesis 256¨C7

    Haemorrhage 790

    Hyperthermia 790, 838

    Hypoglycaemia 214, 834

    Hypothermia 848

    Intracranial pressure, raised 830

    Ischaemic limb 656

    Malaria 416

    Malignant hyperpyrexia 572

    Index to emergency topics

    ¡®Don¡¯t go so fast: we¡¯re in a hurry!¡¯¡ªTalleyrand to his coachman.

    Malignant hypertension 140

    Meningitis 822

    Meningococcaemia 822

    Myocardial infarction 796

    Needle pericardiocentesis 773

    Neutropenic sepsis 352

    Obstructive uropathy 641

    Oncological emergencies 528

    Opioid poisoning 842

    Overdose 838¨C44

    Pacemaker, temporary 776

    Pericardiocentesis 773

    Phaeochromocytoma 837

    Pneumonia 816

    Pneumothorax 814

    Poisoning 838¨C44

    Potassium, hyperkalaemia 674

    hypokalaemia 674

    Pulmonary embolism 818

    Respiratory arrest 894 (Fig A3)

    Respiratory failure 188

    Resuscitation 894 (Fig A3)

    Rheumatological emergencies 538

    Shock 790

    Smoke inhalation 847

    Sodium, hypernatraemia 672

    hyponatraemia 672

    Spinal cord compression 466, 543

    Status asthmaticus 810

    Status epilepticus 826

    Stroke 470

    Superior vena cava obstruction 528

    Supraventricular tachycardia (SVT) 806

    Testicular torsion 652

    Thrombotic thrombocytopenic purpura

    (TTP) 315

    Thyroid storm 834

    Transfusion reaction 349

    Varices, bleeding 257, 820

    Vasculitis, acute systemic 556

    Venous thromboembolism, leg 656

    pulmonary 818

    Ventricular arrhythmias 128, 804

    Ventricular failure, left 800

    Ventricular ? brillation 894 (Fig A3)

    Ventricular tachycardia 128, 804

    _OHCM_10e.indb b _OHCM_10e.indb b 02052017 19:06 02052017 19:06Common haematology values

    Haemoglobin men: 130¨C180gL p324

    women: 115¨C160gL p324

    Mean cell volume, MCV 76¨C96fL ª¢p326; ª¡p332

    Platelets 150¨C400 ¡Ö 109

    L p364

    White cells (total) 4¨C11 ¡Ö 109

    L p330

    neutrophils 2.0¨C7.5 ¡Ö 109

    L p330

    lymphocytes 1.0¨C4.5 ¡Ö 109

    L p330

    eosinophils 0.04¨C0.4 ¡Ö 109

    L p330

    Blood gases

    pH 7.35¨C7.45 p670

    PaO2 >10.6kPa p670

    PaCO2 4.7¨C6kPa p670

    Base excess ¡À 2mmolL p670

    UES (urea and electrolytes)

    Sodium 135¨C145mmolL p672

    Potassium 3.5¨C5.3mmolL p674

    Creatinine 70¨C100¦ÌmolL p298¨C301

    Urea 2.5¨C6.7mmolL p298¨C301

    eGFR >60 p669

    LFTS (liver function tests)

    Bilirubin 3¨C17¦ÌmolL p272, p274

    Alanine aminotransferase, ALT 5¨C35IUL p272, p274

    Aspartate transaminase, AST 5¨C35IUL p272, p274

    Alkaline phosphatase, ALP 30¨C130IUL

    (non-pregnant adults)

    p272, p274

    Albumin 35¨C50gL p686

    Cardiac enzymes

    Troponin T <99th percentile of

    upper reference limit:

    value depends on local

    assay

    p119

    Other biochemical values

    Cholesterol <5mmolL p690

    Triglycerides Fasting: 0.5¨C2.3mmolL p690

    Amylase 0¨C180 IUdL p636

    C-reactive protein, CRP <10mgL p686

    Corrected calcium 2.12¨C2.60mmolL p676

    Glucose, fasting 3.5¨C5.5mmolL p206

    Thyroid stimulating hormone, TSH 0.5¨C4.2mUL p216

    For all other reference intervals, see p750¨C7

    _OHCM_10e.indb c _OHCM_10e.indb c 02052017 19:06 02052017 19:06OXFORD HANDBOOK OF

    CLINICAL

    MEDICINE

    TENTH EDITION

    Ian B. Wilkinson

    Tim Raine

    Kate Wiles

    Anna Goodhart

    Catriona Hall

    Harriet O¡¯Neill

    3 _OHCM_10e.indb i _OHCM_10e.indb i 02052017 19:06 02052017 19:06Contents

    Each chapter¡¯s contents are detailed on its ? rst page

    Prefaces to the ? rst and tenth editions iv

    Acknowledgements v

    Symbols and abbreviations vi

    1 Thinking about medicine 0

    2 History and examination 24

    3 Cardiovascular medicine 92

    4 Chest medicine 160

    5 Endocrinology 202

    6 Gastroenterology 242

    7 Renal medicine 292

    8 Haematology 322

    9 Infectious diseases 378

    10 Neurology 444

    11 Oncology and palliative care 518

    12 Rheumatology 538

    13 Surgery 564

    14 Clinical chemistry 662

    15 Eponymous syndromes 694

    16 Radiology 718

    17 Reference intervals, etc. 750

    18 Practical procedures 758

    19 Emergencies 778

    20 References 852

    Index 868

    Early warning score 892

    Cardiac arrest 894

    _OHCM_10e.indb iii _OHCM_10e.indb iii 02052017 19:06 02052017 19:06Preface to the tenth edition

    This is the ? rst edition of the book without either of the original authors¡ªTony Hope

    and Murray Longmore. Both have now moved on to do other things, and enjoy a

    well-earned rest from authorship. In this book, I am joined by a Nephrologist, Gas-

    troenterologist, and trainees destined for careers in Cardiology, Dermatology, and

    General Practice. Five physicians, each with very dif erent interests and approaches,yet bringing their own knowledge, expertise, and styles. When combined with that

    of our specialist and junior readers, I hope this creates a book that is greater than

    the sum of its parts, yet true to the original concept and ethos of the original authors.

    Life and medicine have moved on in the 30 years since the ? rst edition was published,but medicine and science are largely iterative; true novel ¡®ground-breaking¡¯ or ¡®prac-

    tice-changing¡¯ discoveries are rare, to quote Isaac Newton: ¡®If I have seen further, it

    is by standing on the shoulders of giants¡¯. Therefore, when we set about writing this

    edition we drew inspiration from the original book and its authors; updating, adding,and clarifying, but trying to retain the unique feel and perspective that the OHCM has

    provided to generations of trainees and clinicians.

    IBW, 2017

    We wrote this book not because we know so much, but because we know we

    remember so little¡­the problem is not simply the quantity of information, but the

    diversity of places from which it is dispensed. Trailing eagerly behind the surgeon,the student is admonished never to forget alcohol withdrawal as a cause of post-

    operative confusion. The scrap of paper on which this is written spends a month

    in the pocket before being lost for ever in the laundry. At dif erent times, and in

    inconvenient places, a number of other causes may be presented to the student.

    Not only are these causes and aphorisms never brought together, but when, as a

    surgical house oi cer, the former student faces a confused patient, none is to hand.

    We aim to encourage the doctor to enjoy his patients: in doing so we believe he

    will prosper in the practice of medicine. For a long time now, house oi cers have

    been encouraged to adopt monstrous proportions in order to straddle the diverse

    pinnacles of clinical science and clinical experience. We hope that this book will

    make this endeavour a little easier by moving a cumulative memory burden from

    the mind into the pocket, and by removing some of the fears that are naturally felt

    when starting a career in medicine, thereby freely allowing the doctor¡¯s clinical

    acumen to grow by the slow accretion of many, many days and nights.

    RA Hope and JM Longmore, 1985

    Preface to the ? rst edition

    _OHCM_10e.indb iv _OHCM_10e.indb iv 02052017 19:06 02052017 19:06Symbols and abbreviations

    ª¨..........this fact or idea is important

    ªÃ .......don¡¯t dawdle!¡ªprompt action saves lives

    1 ...........reference

    ªÓ:ªÔ......male-to-female ratio. ªÓ:ªÔ=2:1 means twice as

    common in males

    ª¹ .........therefore

    ~ ..........approximately

    ¨Cve ......negative (+ve is positive)

    ª¡ ª¢ ........ increased or decreased

    ªª .......normal (eg serum level)

    1¡ã ........primary

    2¡ã ........secondary

    ªÒ ..........diagnosis

    ªÒªÒ ........dif erential diagnosis

    A:CR ......albumin to creatinine ratio (mgmmol)

    A2 .........aortic component of the 2nd heart sound

    Ab ......antibody

    ABC ......airway, breathing, and circulation

    ABG .....arterial blood gas: PaO2, PaCO2, pH, HCO3

    ABPA ....allergic bronchopulmonary aspergillosis

    ACE-i .....angiotensin-converting enzyme inhibitor

    ACS .......acute coronary syndrome

    ACTH ....adrenocorticotrophic hormone

    ADH .....antidiuretic hormone

    AF ........atrial ? brillation

    AFB ......acid-fast bacillus

    Ag .......antigen

    AIDS ....acquired immunode? ciency syndrome

    AKI ........acute kidney injury

    ALL ......acute lymphoblastic leukaemia

    ALP ......alkaline phosphatase

    AMA ....antimitochondrial antibody

    AMP .....adenosine monophosphate

    ANA .....antinuclear antibody

    ANCA ...antineutrophil cytoplasmic antibody

    APTT ....activated partial thromboplastin time

    AR ........aortic regurgitation

    ARB .....angiotensin II receptor ¡®blocker¡¯ (antagonist)

    ARDS ...acute respiratory distress syndrome

    ART ......antiretroviral therapy

    AS ........aortic stenosis

    ASD .....atrial septal defect

    AST ......aspartate transaminase

    ATN ......acute tubular necrosis

    ATP ......adenosine triphosphate

    AV ........atrioventricular

    AVM .....arteriovenous malformation(s)

    AXR .....abdominal X-ray (plain)

    Ba ........barium

    BAL ......bronchoalveolar lavage

    bd .......bis die (Latin for twice a day)

    BKA .....below-knee amputation

    BNF ......British National Formulary

    BNP ......brain natriuretic peptide

    BP ........blood pressure

    BPH ......benign prostatic hyperplasia

    bpm ....beats per minute

    ca ........cancer

    CABG ...coronary artery bypass graft

    cAMP ...cyclic adenosine monophosphate (AMP)

    CAPD ...continuous ambulatory peritoneal dialysis

    CCF ......congestive cardiac failure (ie left and right heart

    failure)

    CCU ......coronary care unit

    CDT ......Clostridium dif? cile toxin

    CHB ......complete heart block

    CHD ......coronary heart disease

    CI .........contraindications

    CK ........creatine (phospho)kinase

    CKD ......chronic kidney disease

    CLL ......chronic lymphocytic leukaemia

    CML .....chronic myeloid leukaemia

    CMV .....cytomegalovirus

    CNS ......central nervous system

    COC ......combined oral contraceptive pill

    COPD ....chronic obstructive pulmonary disease

    CPAP ....continuous positive airway pressure

    CPR ......cardiopulmonary resuscitation

    CRP ......c-reactive protein

    CSF ......cerebrospinal ? uid

    CT ........computed tomography

    CVA ......cerebrovascular accident

    CVP ......central venous pressure

    CVS ......cardiovascular system

    CXR ......chest x-ray

    d ..........day(s); also expressed as 7; months are 12

    DC ........direct current

    DIC ......disseminated intravascular coagulation

    DIP ......distal interphalangeal

    dL .......decilitre

    DM .......diabetes mellitus

    DOAC ...direct oral anticoagulant

    DU ........duodenal ulcer

    DV .....diarrhoea and vomiting

    DVT ......deep venous thrombosis

    DXT ......deep radiotherapy

    EBV ......Epstein¨CBarr virus

    ECG ......electrocardiogram

    Echo ...echocardiogram

    EDTA ....ethylene diamine tetra-acetic acid (anticoagulant

    coating, eg in FBC bottles)

    EEG ......electroencephalogram

    eGFR ....estimated glomerular ? ltration rate (in mL

    min1.73m2)

    ELISA ...enzyme-linked immunosorbent assay

    EM .......electron microscope

    EMG .....electromyogram

    ENT ......ear, nose, and throat

    ERCP ....endoscopic retrograde cholangiopancreatography

    ESR ......erythrocyte sedimentation rate

    ESRF ....end-stage renal failure

    EUA ......examination under anaesthesia

    FBC ......full blood count

    FDP ......? brin degradation products

    FEV1 .....forced expiratory volume in 1st sec

    FiO2 ....partial pressure of O2 in inspired air

    FFP ......fresh frozen plasma

    FSH ......follicle-stimulating hormone

    FVC ......forced vital capacity

    g ..........gram

    G6PD ....glucose-6-phosphate dehydrogenase

    GA .......general anaesthetic

    GCS ......Glasgow Coma Scale

    GFR ......glomerular ? ltration rate

    GGT ......gamma-glutamyl transferase

    GH ........growth hormone

    GI ........gastrointestinal

    GN ........glomerulonephritis

    GP ........general practitioner

    GPA ......granulomatosis with polyangiitis (formerly

    Wegener¡¯s granulomatosis)

    GTN ......glyceryl trinitrate

    GTT ......glucose tolerance test

    GU(M) ..genitourinary (medicine)

    h ..........hour

    HAV .....hepatitis A virus

    Hb .......haemoglobin

    HbA1c .glycated haemoglobin

    HBSAg ..hepatitis B surface antigen

    HBV .....hepatitis B virus

    HCC ......hepatocellular cancer

    HCM .....hypertrophic obstructive cardiomyopathy

    Hct ......haematocrit

    HCV ......hepatitis C virus

    HDV .....hepatitis D virus

    HDL ......high-density lipoprotein

    HHT ......hereditary haemorrhagic telangiectasia

    HIV ......human immunode? ciency virus

    HLA ......human leucocyte antigen

    HONK ...hyperosmolar non-ketotic (coma)

    HPV ......human papillomavirus

    HRT ......hormone replacement therapy

    HSP ......Henoch¨CSch?nlein purpura

    HSV ......herpes simplex virus

    HUS ......haemolytic uraemic syndrome

    IBD ...... in? ammatory bowel disease

    IBW ..... ideal body weight

    ICD ...... implantable cardiac de? brillator

    ICP ....... intracranial pressure

    IC(T)U .. intensive care unit

    IDDM ... insulin-dependent diabetes mellitus

    IFN-ªÆ .. interferon alpha

    IE ......... infective endocarditis

    Ig ........ immunoglobulin

    IHD ...... ischaemic heart disease

    IM ........ intramuscular

    INR ...... international normalized ratio

    IP ......... interphalangeal

    IPPV .... intermittent positive pressure ventilation

    ITP ....... idiopathic thrombocytopenic purpura

    IU ........ international unit

    IVC ...... inferior vena cava

    IV(I) .... intravenous (infusion)

    IVU ...... intravenous urography

    JVP ...... jugular venous pressure

    K ..........potassium

    kg .......kilogram

    KPa ......kiloPascal

    L .......... litre

    LAD ........left axis deviation on the ECG

    LBBB .... left bundle branch block

    LDH ...... lactate dehydrogenase

    LDL ...... low-density lipoprotein

    LFT ...... liver function test

    _OHCM_10e.indb vi _OHCM_10e.indb vi 02052017 19:06 02052017 19:06LH ........ luteinizing hormone

    LIF ....... left iliac fossa

    LKKS .... liver, kidney (R), kidney (L), spleen

    LMN ..... lower motor neuron

    LMWH .. low-molecular-weight heparin

    LOC ...... loss of consciousness

    LP ........ lumbar puncture

    LUQ ...... left upper quadrant

    LV ........ left ventricle of the heart

    LVF ....... left ventricular failure

    LVH ...... left ventricular hypertrophy

    MAI .....Mycobacterium avium intracellulare

    MALT ...mucosa-associated lymphoid tissue

    mane ..morning (from Latin)

    MAOI ...monoamine oxidase inhibitor

    MAP .....mean arterial pressure

    MCS ...microscopy, culture, and sensitivity

    mcg ....microgram

    MCP .....metacarpo-phalangeal

    MCV .....mean cell volume

    MDMA ..3,4-methylenedioxymethamphetamine

    ME .......myalgic encephalomyelitis

    mg ......milligram

    MI ........myocardial infarction

    min(s) minute(s)

    mL .......millilitre

    mmHg millimetres of mercury

    MND .....motor neuron disease

    MR .......modi? ed release or mitral regurgitation

    MRCP ...magnetic resonance cholangiopancreatography

    MRI ......magnetic resonance imaging

    MRSA ...meticillin-resistant Staph. aureus

    MS .......multiple sclerosis

    MSM ....men who have sex with men

    MSU .....midstream urine

    NV .....nausea andor vomiting

    NAD .....nothing abnormal detected

    NBM .....nil by mouth

    ND ........noti? able disease

    NEWS ..National Early Warning Score

    ng .......nanogram

    NG ........nasogastric

    NHS .....National Health Service (UK)

    NICE ....National Institute for Health and Care Excellence,http:www.nice.org.uk

    NIDDM .non-insulin-dependent diabetes mellitus

    NMDA ..N-methyl-D-aspartate

    NNT .....number needed to treat

    nocte ..at night

    NR ........normal range (=reference interval)

    NSAID ..non-steroidal anti-in? ammatory drug

    OCP ......oral contraceptive pill

    od .......omni die (Latin for once daily)

    OGD .....oesophagogastroduodenoscopy

    OGTT ....oral glucose tolerance test

    OHCS ....Oxford Handbook of Clinical Specialties

    om ......omni mane (in the morning)

    on .......omni nocte (at night)

    OPD ......outpatients department

    OT ........occupational therapist

    P:CR .....protein to creatinine ratio (mgmmol)

    P2 .........pulmonary component of 2nd heart sound

    PaCO2 ...partial pressure of CO2 in arterial blood

    PAN ......polyarteritis nodosa

    PaO2 .....partial pressure of O2 in arterial blood

    PBC ......primary biliary cirrhosis

    PCR ......polymerase chain reaction

    PCV ......packed cell volume

    PE ........pulmonary embolism

    PEEP ....positive end-expiratory pressure

    PEF(R) ..peak expiratory ? ow (rate)

    PERLA ..pupils equal and reactive to light and

    accommodation

    PET ......positron emission tomography

    PID ......pelvic in? ammatory disease

    PIP .......proximal interphalangeal (joint)

    PMH .....past medical history

    PND .....paroxysmal nocturnal dyspnoea

    PO ........per os (by mouth)

    PPI .......proton pump inhibitor, eg omeprazole

    PR ........per rectum (by the rectum)

    PRL ......prolactin

    PRN ......pro re nata (Latin for as required)

    PRV ......polycythaemia rubra vera

    PSA ......prostate-speci? c antigen

    PTH ......parathyroid hormone

    PTT ......prothrombin time

    PUO ......pyrexia of unknown origin

    PV ........per vaginam (by the vagina, eg pessary)

    PVD ......peripheral vascular disease

    QDS ......quater die sumendus; take 4 times daily

    qqh .....quarta quaque hora: take every 4h

    R ..........right

    RA ........rheumatoid arthritis

    RAD .....right axis deviation on the ECG

    RBBB ...right bundle branch block

    RBC ......red blood cell

    RCT ......randomized controlled trial

    RDW ....red cell distribution width

    RFT ......respiratory function tests

    Rh ........Rhesus status

    RIF .......right iliac fossa

    RRT ......renal replacement therapy

    RUQ .....right upper quadrant

    RV ........right ventricle of heart

    RVF ......right ventricular failure

    RVH ......right ventricular hypertrophy

    ªµ .........recipe (Latin for treat with)

    ssec ...second(s)

    S1, S2 ....? rst and second heart sounds

    SBE ......subacute bacterial endocarditis

    SC ........subcutaneous

    SD ........standard deviation

    SE ........side-ef ect(s)

    SIADH ..syndrome of inappropriate anti-diuretic hormone

    secretion

    SL ........sublingual

    SLE ......systemic lupus erythematosus

    SOB ......short of breath

    SOBOE .short of breath on exertion

    SpO2 ....peripheral oxygen saturation (%)

    SR ........slow-release

    Stat ....statim (immediately; as initial dose)

    STDI ...sexually transmitted diseaseinfection

    SVC ......superior vena cava

    SVT ......supraventricular tachycardia

    T¡ã .........temperature

    t? ........biological half-life

    T3 ........tri-iodothyronine

    T4 ........thyroxine

    TB ........tuberculosis

    TDS ......ter die sumendus (take 3 times a day)

    TFT ......thyroid function test (eg TSH)

    TIA ......transient ischaemic attack

    TIBC ....total iron-binding capacity

    TPN ......total parenteral nutrition

    TPR ......temperature, pulse, and respirations count

    TRH ......thyrotropin-releasing hormone

    TSH ......thyroid-stimulating hormone

    TTP ......thrombotic thrombocytopenic purpura

    U ..........units

    UC ........ulcerative colitis

    UE .....urea and electrolytes and creatinine

    UMN .....upper motor neuron

    URT(I) ..upper respiratory tract (infection)

    US(S) ....ultrasound (scan)

    UTI ......urinary tract infection

    VDRL ....Venereal Diseases Research Laboratory

    VE ........ventricular extrasystole

    VF ........ventricular ? brillation

    VHF ......viral haemorrahgic fever

    VMA ....vanillylmandelic acid (HMMA)

    VQ .......ventilationperfusion scan

    VRE ......vancomycin resistant enterococci

    VSD ......ventricular-septal defect

    VT ........ventricular tachycardia

    VTE ......venous thromboembolism

    WBC ....white blood cell

    WCC ....white blood cell count

    wk(s) ..week(s)

    yr(s) ...year(s)

    ZN ........Ziehl¨CNeelsen stain, eg for mycobacteria

    _OHCM_10e.indb vii _OHCM_10e.indb vii 02052017 19:06 02052017 19:06_OHCM_10e.indb viii _OHCM_10e.indb viii 02052017 19:06 02052017 19:06¡®He who studies medicine without books sails an unchartered sea, but he who

    studies medicine without patients does not go to sea at all¡¯

    William Osler 1849¨C1919

    The word ¡®patient¡¯ occurs frequently throughout this book.

    Do not skim over it lightly.

    Rather pause and dof your metaphorical cap, of ering due respect to those

    who by the opening up of their lives to you, become your true teachers.

    Without your patients, you are a technician with a useless skill.

    With them, you are a doctor.

    _OHCM_10e.indb ix _OHCM_10e.indb ix 02052017 19:06 02052017 19:061 Thinking about medicine

    Contents

    The Hippocratic oath 1

    Medical care 2

    Compassion 3

    The diagnostic puzzle 4

    Being wrong 5

    Duty of candour 5

    Bedside manner and communication

    skills 6

    Prescribing drugs 8

    Surviving life on the wards 10

    Death 12

    Medical ethics 14

    Psychiatry on medical and surgical

    wards 15

    The older person 16

    The pregnant woman 17

    Epidemiology 18

    Randomized controlled trials 19

    Medical mathematics 20

    Evidence-based medicine (EBM) 22

    Medicalization 23

    Fig 1.1 Asclepius, the god of healing and his three

    daughters, Meditrina (medicine), Hygieia (hy-

    giene), and Panacea (healing). The staf and single

    snake of Asclepius should not be confused with

    the twin snakes and caduceus of Hermes, the dei-

    ¡¤ ed trickster and god of commerce, who is viewed

    with disdain.

    Plate from Aubin L Millin, Galerie Mythologique (1811)

    We thank Dr Kate Mans? eld, our Specialist Reader, for her contribution to this chapter.

    _OHCM_10e.indb x _OHCM_10e.indb x 02052017 19:06 02052017 19:06Thinking about medicine

    1 The Hippocratic oath ~4th century BC

    I

    swear by Apollo the physician and Asclepius and Hygieia and Panacea and all the

    gods and goddesses, making them my witnesses, that I will ful? l according to my

    ability and judgement this oath and this covenant.

    T

    o hold him who has taught me this art as equal to my parents and to live my

    life in partnership with him, and if he is in need of money to give him a share of

    mine, and to regard his of spring as equal to my own brethren and to teach them

    this art, if they desire to learn it, without fee and covenant. I will impart it by pre-

    cept, by lecture and by all other manner of teaching, not only to my own sons but

    also to the sons of him who has taught me, and to disciples bound by covenant and

    oath according to the law of physicians, but to none other.

    T

    he regimen I shall adopt shall be to the bene? t of the patients to the best of

    my power and judgement, not for their injury or any wrongful purpose.

    I

    will not give a deadly drug to anyone though it be asked of me, nor will I lead

    the way in such counsel.

    1

    And likewise I will not give a woman a pessary to pro-

    cure abortion.

    2

    But I will keep my life and my art in purity and holiness. I will not

    use the knife,3

    not even, verily, on suf erers of stone but I will give place to such as

    are craftsmen therein.

    Whatsoever house I enter, I will enter for the bene? t of the sick, refraining

    from all voluntary wrongdoing and corruption, especially seduction of male

    or female, bond or free.

    Whatsoever things I see or hear concerning the life of men, in my attend-

    ance on the sick, or even apart from my attendance, which ought not to

    be blabbed abroad, I will keep silence on them, counting such things to be as reli-

    gious secrets.

    I

    f I ful? l this oath and do not violate it, may it be granted to me to enjoy life and

    art alike, with good repute for all time to come; but may the contrary befall me

    if I transgress and violate my oath.

    Paternalistic, irrelevant, inadequate, and possibly plagiarized from the followers of

    Pythagoras of Samos; it is argued that the Hippocratic oath has failed to evolve

    into anything more than a right of passage for physicians. Is it adequate to address

    the scienti? c, political, social, and economic realities that exist for doctors today?

    Certainly, medical training without a fee appears to have been con? ned to history.

    Yet it remains one of the oldest binding documents in history and its principles of

    commitment, ethics, justice, professionalism, and con? dentiality transcend time.

    The absence of autonomy as a fundamental tenet of modern medical care can

    be debated. But just as anatomy and physiology have been added to the doctor¡¯s

    repertoire since Hippocrates, omissions should not undermine the oath as a para-

    digm of self-regulation amongst a group of specialists committed to an ideal. And

    do not forget that illness may represent a temporary loss of autonomy caused by

    fear, vulnerability, and a subjective weighting of present versus future. It could

    be argued that Hippocratic paternalism is, in fact, required to restore autonomy.

    Contemporary versions of the oath often fail to make doctors accountable for

    keeping to any aspect of the pledge. And beware the oath that is nothing more

    than historic ritual without accountability, for then it can be superseded by per-

    sonal, political, social, or economic priorities:

    ¡®In Auschwitz, doctors presided over the murder of most of the one million

    victims¡­. [They] did not recall being especially aware in Auschwitz of their

    Hippocratic oath, and were not surprisingly, uncomfortable discussing it¡­The

    oath of loyalty to Hitler¡­was much more real to them.¡¯

    Robert Jay Lifton, The Nazi Doctors.

    The endurance of the Hippocratic oath

    1 This is unlikely to be a commentary on euthanasia (easeful death) as the oath predates the word. Rather,it is believed to allude to the common practice of using doctors as political assassins.

    2 Abortion by oral methods was legal in ancient Greece. The oath cautions only against the use of pessaries

    as a potential source of lethal infection.

    3 The oath does not disavow surgery, merely asks the physician to cede to others with expertise.

    _OHCM_10e.indb 1 _OHCM_10e.indb 1 02052017 19:06 02052017 19:062

    Thinking about medicine

    Medical care

    Advice for doctors

    ¡¤ Do not blame the sick for being sick.

    ¡¤ Seek to discover your patient¡¯s wishes and comply with them.

    ¡¤ Learn.

    ¡¤Work for your patients, not your consultant.

    ¡¤ Respect opinions.

    ¡¤ Treat a patient, not a disease.

    ¡¤ Admit a person, not a diagnosis.

    ¡¤ Spend time with the bereaved; help them to shed tears.

    ¡¤ Give the patient (and yourself) time: for questions, to re? ect, and to allow healing.

    ¡¤ Give patients the bene? t of the doubt.

    ¡¤ Be optimistic.

    ¡¤ Be kind to yourself: you are not an inexhaustible resource.

    ¡¤ Question your conscience.

    ¡¤ Tell the truth.

    ¡¤ Recognize that the scienti? c approach may be ? nite, but experience and empathy

    are limitless.

    The National Health Service

    ¡®The resources of medical skill and the apparatus of healing shall be placed at

    the disposal of the patient, without charge, when he or she needs them; that

    medical treatment and care should be a communal responsibility, that they

    should be made available to rich and poor alike in accordance with medical need

    and by no other criteria...Society becomes more wholesome, more serene, and

    spiritually healthier, if it knows that its citizens have at the back of their con-

    sciousness the knowledge that not only themselves, but all their fellows, have ac-

    cess, when ill, to the best that medical skill can provide...You can always ¡®pass by

    on the other side¡¯. That may be sound economics. It could not be worse morals.¡¯

    Aneurin Bevan, In Place of Fear, 1952.

    In 2014, the Commonwealth Fund presented an overview of international healthcare

    systems examining ? nancing, governance, healthcare quality, ei ciency, evidence-

    based practice, and innovation. In a scoring system of 11 nations across 11 catego-

    ries, the NHS came ? rst overall, at less than half the cost per head spent in the USA.1

    The King¡¯s Fund debunks the myth that the NHS is unaf ordable in the modern era,2

    although funding remains a political choice. Bevan prophesied, ¡®The NHS will last as

    long as there are folk left with the faith to ? ght for it.¡¯ Guard it well.

    Decision and intervention are the essence of action,re? ection and conjecture are the essence of thought;

    the essence of medicine is combining these in the ser-

    vice of others. We of er our ideals to stimulate thought

    and action: like the stars, ideals are hard to reach, but

    they are used for navigation. Orion (? g 1.2) is our star

    of choice. His constellation is visible across the globe

    so he links our readers everywhere, and he will remain

    recognizable long after other constellations have dis-

    torted.

    Medicine and the stars

    Fig 1.2 The const ellation of Orion has three superb stars: Bel-

    latrix (the stetho scope¡¯s bell), Betel geuse (B), and Rigel (R). The

    three stars at the cross over (Orion¡¯s Belt) are Alnitak, Alnilam, and

    Mint a ka.

    ¡¤JML and David Malin.

    _OHCM_10e.indb 2 _OHCM_10e.indb 2 02052017 19:06 02052017 19:06Thinking about medicine

    3

    QALYS and resource rationing

    ¡®There is a good deal of hit and miss about general medicine. It is a profession

    where exact measurement is not easy and the absence of it opens the mind to

    endless conjecture as to the ef? cacy of this or that form of treatment.¡¯

    Aneurin Bevan, In Place of Fear, 1952.

    A QALY is a quality-adjusted life year. One year of healthy life expectancy = 1 QALY,whereas 1 year of unhealthy life expectancy is worth <1 QALY, the precise value falling

    with progressively worsening quality of life. If an intervention means that you are

    likely to live for 8 years in perfect health then that intervention would have a QALY

    value of 8. If a new drug improves your quality of life from 0.5 to 0.7 for 25 years,then it has a QALY value of (0.7 ¦¸ 0.5)¡Ö25=5. Based on the price of the intervention, the

    cost of 1 QALY can be calculated. Healthcare priorities can then be weighted towards

    low cost QALYs. The National Institute for Health and Care Excellence (NICE) consid-

    ers that interventions for which 1 QALY=<¡ê30 000 are cost-ef ective. However, as a

    practical application of utilitarian theory, QALYs remain open to criticism (table 1.1).

    Remember that although for a clinician, time is unambiguous and quanti? able, time

    experienced by patients is more like literature than science: a minute might be a

    chapter, a year a single sentence.3

    Table 1.1 The advantages and disadvantages of QALYs

    Advantages Disadvantages

    Transparent societal decision

    making

    Focuses on slice (disease), not pie (health)

    Common unit for dif erent

    interventions

    Based on a value judgement that living longer is a

    measure of success

    Allows cost-ef ectiveness

    analysis

    Quality of life assessment comes from general public,not those with disease

    Allows international comparison Potentially ageist¡ªthe elderly always have less ¡®life

    expectancy¡¯ to gain

    Focus on outcomes, not process ie care, compassion

    The inverse care law, equity, and distributive justice:

    The inverse care law states that the availability of good medical care varies inversely

    with the need for it. This arises due to poorer quality services, barriers to service ac-

    cess, and external disadvantage. By focusing on the bene? t gained from an interven-

    tion, the QALY system treats everyone as equal. But is this really equality? Distributive

    justice is the distribution of ¡®goods¡¯ so that those who are worst of become better

    of .

    In healthcare terms, this means allocation of resources to those in greatest need,regardless of QALYs.

    The importance of compassion4

    ,5 in medicine is undisputed. It is an emotional re-

    sponse to negativity or suf ering that motivates a desire to help. It is more than

    ¡®pity¡¯, which has connotations of inferiority; and dif erent from ¡®empathy¡¯, which is

    a vicarious experience of the emotional state of another. It requires imaginative

    indwelling into another¡¯s condition. The ? ctional Jules Henri experiences a loss of

    sense of the second person; another person¡¯s despair alters his perception of the

    world so that they are ¡®connected in some universal, though unseen, pattern of

    humanity¡¯.

    4

    With compassion, the pain of another is ¡®intensi? ed by the imagina-

    tion and prolonged by a hundred echoes¡¯.

    5

    Compassion cannot be taught; it re-

    quires engagement with suf ering, cultural understanding, and a mutuality, rather

    than paternalism. Adverse political, excessively mechanical, and managerial envi-

    ronments discourage its expression. When compassion (what is felt) is dii cult,etiquette (what is done) must not fail: re? ection, empathy, respectfulness, atten-

    tion, and manners count: ¡®For I could never even have prayed for this: that you

    would have pity on me and endure my agonies and stay with me and help me¡¯.

    6

    Compassion

    4 Sebastian Faulkes, Human Traces, 2005.

    5 Milan Kundera, The Unbearable Lightness of Being, 1984.

    6 Philoctetes by Sophocles 409 BC (translation Phillips and Clay, 2003).

    _OHCM_10e.indb 3 _OHCM_10e.indb 3 02052017 19:06 02052017 19:064

    Thinking about medicine

    The diagnostic puzzle

    How to formulate a diagnosis

    Diagnosing by recognition: For students, this is the most irritating method. You

    spend an hour asking all the wrong questions, and in waltzes a doctor who names

    the disease before you have even ? nished taking the pulse. This doctor has simply

    recognized the illness like he recognizes an old friend (or enemy).

    Diagnosing by probability: Over our clinical lives we build up a personal database

    of diagnoses and associated pitfalls. We unconsciously run each new ¡®case¡¯ through

    this continuously developing probabilistic algorithm with increasing speed and ef-

    fortlessness.

    Diagnosing by reasoning: Like Sherlock Holmes, we must exclude each dif erential,and the diagnosis is what remains. This is dependent on the quality of the dif erential

    and presupposes methods for absolutely excluding diseases. All tests are statistical

    rather than absolute (5% of the population lie outside the ¡®normal¡¯ range), which is

    why this method remains, like Sherlock Holmes, ? ctional at best.

    Diagnosing by watching and waiting: The dangers and expense of exhaustive tests

    may be obviated by the skilful use of time.

    Diagnosing by selective doubting: Diagnosis relies on clinical signs and investiga-

    tive tests. Yet there are no hard signs or perfect tests. When diagnosis is dii cult, try

    doubting the signs, then doubting the tests. But the game of medicine is unplayable

    if you doubt everything: so doubt selectively.

    Diagnosis by iteration and reiteration: A brief history suggests looking for a few

    signs, which leads to further questions and a few tests. As the process reiterates,various diagnostic possibilities crop up, leading to further questions and further

    tests. And so history taking and diagnosing never end.

    Heuristic pitfalls

    Heuristics are the cognitive shortcuts which allow quick decision-making by focus-

    ing on relevant predictors. Be aware of them so you can be vigilant of their traps.7

    Representativeness: Diagnosis is driven by the ¡®classic case¡¯. Do not forget the

    atypical variant.

    Availability: The diseases that we remember, or treated most recently, carry more

    weight in our diagnostic hierarchy. Question whether this more readily available

    information is truly relevant.

    Overcon? dence: Are you overestimating how much you know and how well you

    know it? Probably.

    Bias: The hunt for, and recall of, clinical information that ? ts with our expectations.

    Can you disprove your own diagnostic hypothesis?

    Illusory correlation: Associated events are presumed to be causal. But was it treat-

    ment or time that cured the patient?

    Consider three wise men:6

    Occam¡¯s razor: Entia non sunt multiplicanda praeter necessitatem translates as

    ¡®entities must not be multiplied unnecessarily¡¯. The physician should therefore seek

    to achieve diagnostic parsimony and ? nd a single disease to explain all symptoms,rather than prof er two or three unrelated diagnoses.

    Hickam¡¯s dictum: Patients can have as many diagnoses as they damn well

    please. Signs and symptoms may be due to more than one pathology. Indeed, a

    patient is statistically more likely to have two common diagnoses than one unify-

    ing rare condition.

    Crabtree¡¯s bludgeon: No set of mutually inconsistent observations can exist for

    which some human intellect cannot conceive a coherent explanation however

    complicated. This acts as a reminder that physicians prefer Occam to Hickam: a

    unifying diagnosis is a much more pleasing thing. Con? rmation bias then ensues

    as we look for supporting information to ? t with our unifying theory. Remember

    to test the validity of your diagnosis, no matter how pleasing it may seem.

    A razor, a dictum, and a bludgeon

    _OHCM_10e.indb 4 _OHCM_10e.indb 4 02052017 19:06 02052017 19:06Thinking about medicine

    5

    It is always possible to be wrong8 because you remain unaware of it while it is

    happening. Such error-blindness is why ¡®I am wrong¡¯ is a statement of impos-

    sibility. Once you are aware that you are wrong, you are no longer wrong, and can

    therefore only declare ¡®I was wrong¡¯. It is also the reason that fallibility must be

    accepted as a universally human phenomenon. Conversely, certainty is the convic-

    tion that we cannot be wrong because our biases and beliefs must be grounded

    in fact. Certainty produces the comforting illusion that the world (and medicine)

    is knowable. But be cautious of certainty for it involves a shift in perspective

    inwards, towards our own convictions. This means that other people¡¯s stories can

    cease to matter to us. Certainty becomes lethal to empathy.

    In order to determine how and why mistakes are made, error must be acknowl-

    edged and accepted. Defensiveness is bad for progress. ¡®I was wrong, but...¡¯ is

    rarely an open and honest analysis of error that will facilitate dif erent and better

    action in the future. It is only with close scrutiny of mistakes that you can see the

    possibility of change at the core of error. And yet, medical practice is littered with

    examples of resistance to disclosure, and reward for the concealment of error.

    This must change.4 Remember error blindness and protect your whistle-blowers.

    Listen. It is an act of humility that acknowledges the position of others, and the

    possibility of error in yourself. Knowledge persists only until it can be disproved.

    Better to aspire to the aporia of Socrates:

    ¡®At ? rst, he didn¡¯t know...just as he doesn¡¯t yet know the answer now either;

    but he still thought he knew the answer then, and he was answering con-

    ¡¤ dently, as if he had knowledge. He didn¡¯t think he was stuck before, but

    now he appreciates that he is stuck...At any rate, it would seem that we¡¯ve

    increased his chances of ? nding out the truth of the matter, because now,given his lack of knowledge, he¡¯ll be glad to undertake the investigation...Do

    you think he¡¯d have tried to enquire or learn about this matter when he thought

    he knew it (even though he didn¡¯t), until he¡¯d become bogged down and stuck,and had come to appreciate his ignorance and to long for knowledge?¡¯

    Plato: Meno and other dialogues, 402 BC; Water? eld translation, 2005.

    Being wrong

    In a world in which a ¡®mistake¡¯ can be rede? ned as a ¡®complication¡¯, it is easy to

    conceal error behind a veil of technical language. In 2014, a professional duty of

    candour became statutory in England for incidents that cause death, severe or

    moderate harm, or prolonged psychological harm. As soon as practicable, the pa-

    tient must be told in person what happened, given details of further enquiries, and

    of ered an apology. But this should not lead to the prof ering of a ¡®tick-box¡¯ apology

    of questionable value. Be reassured that an apology is not an admission of liability.

    Risks and imperfections are inherent to medicine and you have the freedom to

    be sorry whenever they occur. Focus not on legislation, but on transparency and

    learning. The ethics of forgiveness require a complete response in which the pa-

    tient¡¯s voice is placed at the heart of the process.9

    Duty of candour

    Error provides a link between medicine and the humanities. Both strive to bridge

    the gap between ourselves and the world. Medicine attempts to do this in an ob-

    jective manner, using disproved hypotheses (error) to progress towards a ¡®truth¡¯.

    Art, however, accepts the unknown, and celebrates transience and subjectivity.

    By seeing the world through someone else¡¯s eyes, art teaches us empathy. It is at

    the point where art and medicine collide that doctors can re-attach themselves

    to the human race and feel those emotions that motivate or terrify our patients.

    ¡®Unknowing¡¯ drives medical theory, but also stories and pictures. And these are the

    hallmark of our highest endeavours.

    ¡®We all know that Art is not truth. Art is a lie that makes us realise the truth,at least the truth that is given to us to understand.¡¯

    Pablo Picasso in Picasso Speaks, 1923.

    Medicine, error, and the humanities

    _OHCM_10e.indb 5 _OHCM_10e.indb 5 02052017 19:06 02052017 19:066

    Thinking about medicine

    Bedside manner and communication skills

    A good bedside manner is dynamic. It develops in the light of a patient's needs and is

    grounded in honesty, humour, and humility, in the presence of human weakness. But

    it is fragile: `It is unsettling to ? nd how little it takes to defeat success in medicine...

    You do not imagine that a mere matter of etiquette could foil you. But the social

    dimension turns out to be as essential as the scienti? c... How each interaction is

    negotiated can determine whether a doctor is trusted, whether a patient is heard,whether the right diagnosis is made, the right treatment given. But in this realm

    there are no perfect formulas.' (Atul Gawande, Better: A Surgeon's Notes on Performance, 2008)

    A patient may not care how much you know, until they know how much you care.

    Without care and trust, there can be little healing. Pre-set formulas of er, at best,a guide:

    Introduce yourself every time you see a patient, giving your name and your role.

    ¡®Introductions are about making a human connection between one human being

    who is suffering and vulnerable, and another human being who wishes to help.

    They begin therapeutic relationships and can instantly build trust¡¯

    Kate Granger, hellomynameis.org.uk, hellomynameis

    Be friendly. Smile. Sit down. Take an interest in the patient and ask an unscripted

    question. Use the patient¡¯s name more than once.

    Listen. Do not be the average physician who interrupts after 20¨C30 seconds.

    ¡®Look wise, say nothing, and grunt. Speech was given to conceal thought.¡¯

    William Osler (1849¨C1919).

    Increase the wait-time between listening and speaking. The patient may say more.

    Pay attention to the non-verbal. Observe gestures, body language, and eye contact.

    Be aware of your own.

    Explain. Consider written or drawn explanations. When appropriate, include rela-

    tives in discussions to assist in understanding and recall.

    Adapt your language. An explanation in ? uent medicalese may mean nothing to

    your patient.

    Clarify understanding. ¡®Acute¡¯, ¡®chronic¡¯, ¡®dizzy¡¯, ¡®jaundice¡¯, ¡®shock¡¯, ¡®malignant¡¯, ¡®re-

    mission¡¯: do these words have the same meaning for both you and your patient?

    Be polite. It requires no talent.

    ¡®Politeness is prudence and consequently rudeness is folly. To make enemies by

    being...unnecessarily rude is as crazy as setting one¡¯s house on ? re.¡¯

    Arthur Schopenhauer (1788¨C1860).

    Address silent fears. Give patients a chance to raise their concerns: ¡®What are you

    worried this might be?¡¯, ¡®Some people worry about...., does that worry you?¡¯

    Consider the patient¡¯s disease model. Patients may have their own explanations

    for their symptoms. Acknowledge their theories and, if appropriate, make an ef ort

    to explain why you think them unlikely.

    ¡®A physician is obligated to consider more than a diseased organ, more even than

    the whole man - he must view the man in his world.¡¯

    Harvey Cushing (1869¨C1939).

    Keep the patient informed. Explain your working diagnosis and relate this to their

    understanding, beliefs, and concerns. Let them know what will happen next, and the

    likely timing. ¡®Soon¡¯ may mean a month to a doctor, but a day to a patient. Apologize

    for any delay.

    Summarize. Is there anything you have missed?

    Communication, partnership, and health promotion are improved when doctors are

    trained to KEPe Warm:10

    ¡¤ Knowing¡ªthe patient¡¯s history, social talk.

    ¡¤ Encouraging¡ªback-channelling (hmmm, aahh).

    ¡¤ Physically engaging¡ªhand gestures, appropriate contact, lean in to the patient.

    ¡¤Warm up¡ªcooler, professional but supportive at the start of the consultation,making sure to avoid dominance, patronizing, and non-verbal cut-of s (ie turning

    away from the patient) at the end.

    _OHCM_10e.indb 6 _OHCM_10e.indb 6 02052017 19:06 02052017 19:06Thinking about medicine

    7

    Open questions ¡®How are you?¡¯, ¡®How does it feel?¡¯ The direction a patient

    chooses of ers valuable information. ¡®Tell me about the vomit.¡¯ ¡®It was dark.¡¯

    ¡®How dark?¡¯ ¡®Dark bits in it.¡¯ ¡®Like¡­?¡¯ ¡®Like bits of soil in it.¡¯ This information is

    gold, although it is not cast in the form of cof ee grounds.

    Patient-centred questions Patients may have their own ideas about what

    is causing their symptoms, how they impact, and what should be done. This is

    ever truer as patients frequently consult Dr Google before their GP. Unless their

    ideas, concerns, and expectations are elucidated, your patient may never be

    fully satis? ed with you, or able to be fully involved in their own care.

    Considering the whole Humans are not self-sui cient units; we are complex

    relational beings, constantly reacting to events, environments, and each other.

    To understand your patient¡¯s concerns you must understand their context:

    home-life, work, dreams, fears. Information from family and friends can be very

    helpful for identifying triggering and exacerbating factors, and elucidating the

    true underlying cause. A headache caused by anxiety is best treated not with

    analgesics, but by helping the patient access support.

    Silence and echoes Often the most valuable details are the most dii cult to

    verbalize. Help your patients express such thoughts by giving them time: if you

    interrogate a robin, he will ? y away; treelike silence may bring him to your hand.

    ¡®Trade Secret: the best diagnosticians in medicine are not internists, but pa-

    tients. If only the doctor would sit down, shut up, and listen, the patient will

    eventually tell him the diagnosis.¡¯

    Oscar London, Kill as Few Patients as Possible, 1987.

    Whilst powerful, silence should not be oppressive¡ªtry echoing the last words

    said to encourage your patient to continue vocalizing a particular thought.

    Try to avoid

    Closed questions: These permit no opportunity to deny assumptions. ¡®Have you

    had hip pain since your fall?¡¯ ¡®Yes, doctor.¡¯ Investigations are requested even

    though the same hip pain was also present for many years before the fall!

    Questions suggesting the answer: ¡®Was the vomit black¡ªlike cof ee grounds?¡¯

    ¡®Yes, like cof ee grounds, doctor.¡¯ The doctor¡¯s expectations and hurry to get the

    evidence into a pre-decided format have so tarnished the story as to make it

    useless.

    Asking questions

    Shared decision-making: no decision about me, without me

    Shared decision-making aims to place patients¡¯ needs, wishes, and preferences at

    the centre of clinical decision-making.

    ¡¤ Support patients to articulate their understanding of their condition.

    ¡¤ Inform patients about their condition, treatment options, bene? ts, and risk.

    ¡¤Make decisions based on mutual understanding.

    Consider asking not, ¡®What is the matter?¡¯ but, ¡®What matters to you?¡¯.

    Consider also your tendency towards libertarian paternalism or ¡®nudge¡¯. This is when

    information is given in such a way as to encourage individuals to make a particular

    choice that is felt to be in their best interests, and to correct apparent ¡®reasoning

    failure¡¯ in the patient. This is done by framing the information in either a positive or

    negative light depending on your view and how you might wish to sway your audi-

    ence. Consider the following statements made about a new drug which of ers 96%

    survival compared to 94% with an older drug:

    ¡¤More people survive if they take this drug.

    ¡¤ This new drug reduces mortality by a third.

    ¡¤ This new drug bene? ts only 2% of patients.

    ¡¤ There may be unknown side-ef ects to the new drug.

    How do you choose?

    _OHCM_10e.indb 7 _OHCM_10e.indb 7 02052017 19:06 02052017 19:068

    Thinking about medicine

    Prescribing drugs

    ª¨Consult the BNF or BNF for Children or similar before giving any drug with which

    you are not thoroughly familiar.

    ª¨Check the patient¡¯s allergy status and make all reasonable attempts to qualify the

    reaction (table 1.2). The burden of iatrogenic hospital admission and avoidable drug-

    related deaths is real. Equally, do not deny life-saving treatment based on a mild and

    predictable reaction.

    ª¨Check drug interactions meticulously.

    Table 1.2 Drug reactions

    Type of reaction Examples

    True allergy Anaphylaxis: oedema, urticaria, wheeze (p794¨C5)

    Side-ef ect All medications have side-ef ects. The most common are rash,itch, nausea, diarrhoea, lethargy, and headache

    Increased ef ect

    toxicity

    Due to inter-individual variance. Dosage regimen normally cor-

    rects for this but beware states of altered drug clearance such

    as liver and renal (p305) impairment

    Drug interaction Reaction due to drugs used in combination, eg azathioprine and

    allopurinol, erythromycin and warfarin

    Remember primum non nocere: ? rst do no harm. The more minor the illness, the

    more weight this carries. Overall, doctors have a tendency to prescribe too much

    rather than too little.

    Consider the following when prescribing any medication:

    1 The underlying pathology. Do not let the amelioration of symptoms lead to

    failure of investigation and diagnosis.

    2 Is this prescription according to best evidence?

    3 Drug reactions. All medications come with risks, potential side-ef ects, incon-

    venience to the patient, and expense.

    4 Is the patient taking other medications?

    5 Alternatives to medication. Does the patient really need or want medication?

    Are you giving medication out of a sense of needing to do something, or because

    you genuinely feel it will help the patient? Is it more appropriate to of er infor-

    mation, reassurance, or lifestyle modi? cation?

    6 Is there a risk of overdose or addiction?

    7 Can you assist the patient? Once per day is better than four times. How easy is it

    to open the bottle? Is there an intervention that can help with medicine manage-

    ment, eg a multi-compartment compliance aid, patient counselling, an IT solution

    such as a smartphone app?

    8 Future planning. How are you going to decide whether the medication has

    worked? What are the indications to continue, stop, or change the prescribed

    regimen?

    Pain is often seen as an unequivocally bad thing, and certainly many patients

    dream of a life without pain. However, without pain we are vulnerable to ourselves

    and our behaviours, and risk ignorance of underlying conditions.

    While most children quickly learn not to touch boiling water as their own body

    disciplines their behaviour with the punishment of pain; children born with con-

    genital insensitivity to pain (CIPA) can burn themselves, break bones, and tear skin

    without feeling any immediate ill ef ect. Their health is constantly at risk from

    unconsciously self-mutilating behaviours and unnoticed trauma. CIPA is very rare

    but examples of the human tendency for self-damage without the protective fac-

    tor of pain are common. Have you ever bitten your tongue or cheek after a dental

    anaesthetic? Patients with diabetic neuropathy risk osteomyelitis and arthropa-

    thy in their pain-free feet.

    If you receive a message of bad news, you do not solve the problem by hiding the

    message. Listen to the pain as well as making the patient comfortable.

    In appreciation of pain

    _OHCM_10e.indb 8 _OHCM_10e.indb 8 02052017 19:06 02052017 19:06Thinking about medicine

    9

    The placebo ef ect

    The placebo ef ect is a well-recognized phenomenon whereby patients improve af-

    ter undergoing therapy that is believed by clinicians to have no direct ef ect on the

    pathophysiology of their disease. The nature of the therapy (pills, rituals, massages)

    matters less than whether the patient believes the therapy will help.

    Examples of the placebo ef ect in modern medicine include participants in the pla-

    cebo arm of a clinical trial who see dramatic improvements in their refractory illness,and patients in severe pain who assume the saline ? ush prior to their IV morphine

    is opioid and reporting relief of pain before the morphine has been administered. It

    is likely that much of the symptomatic relief experienced from ¡®active¡¯ medicines in

    fact results from a placebo ef ect.

    The complementary therapy industry has many ingenious ways of utilizing the

    placebo ef ect. These can give great bene? ts to patients, often with minimal risk; but

    there remains the potential for signi? cant harm, both ? nancially and by dissuading

    patients from seeking necessary medical help.

    Why evolution has given us bodies with a degree of self-healing ability in response

    to a belief that healing will happen, and not in response to a desire for healing, is

    unclear. Perhaps the belief that a solution is underway ¡®snoozes¡¯ the internal alarm

    systems that are designed to tell us there is a problem, and so improve the symptoms

    that result from the body¡¯s perception of harm.

    Many patients who receive therapies are unaware of their intended ef ects, thus

    missing out on the narrative that may give them an expectation of improvement. Try

    to ? nd time to discuss with your patients the story of how you hope treatment will

    address their problems.

    Compliance embodies the imbalance of power between doctor and patient: the

    doctor knows best and the patient¡¯s only responsibility is to comply with that

    monopoly of medical knowledge. Devaluing of patients and ethically dubious, the

    term ¡®compliance¡¯ has been relegated from modern prescribing practice. Con-

    cordance is now king: a prescribing agreement that incorporates the beliefs and

    wishes of the patient.

    Only 50¨C70% of patients take medicines as prescribed to them. This leads to

    concern over wasted resources and avoidable illness. Interventions that increase

    concordance are promoted using the mnemonic: Educating Patients Enhances

    Care Received

    ¡¤ Explanation: discuss the bene? ts and risks of taking and not-taking medication.

    Some patients will prefer not to be treated and, if the patient has capacity and

    understands the risks, such a decision should be respected.

    ¡¤ Problems: talk through the patient¡¯s experience of their treatment¡ªhave they

    suf ered side-ef ects which have prompted non-concordance?

    ¡¤ Expectations: discuss what they should expect from their treatment. This is im-

    portant especially in the treatment of silent conditions where there is no symp-

    tomatic bene? t, eg antihypertensive treatment.

    ¡¤ Capability: talk through the medication regimen with them and consider ways

    to reduce its complexity.

    ¡¤ Reinforcement: reproduce your discussion in written form for the patient to take

    home. Check how they are managing their medications when you next see them.

    But remember that there is little evidence that increasing information improves

    concordance. And if concordance is increased solely by the ¡®education¡¯ of the pa-

    tient then it starts to look a lot like compliance.11 A truly shared agreement will

    not always ¡®comply¡¯ or ¡®concord¡¯ with the prescriber. The capacity of the informed

    individual to consent or not, means that in some cases, concordance looks more

    like informed divergence.

    Compliance and concordance

    _OHCM_10e.indb 9 _OHCM_10e.indb 9 02052017 19:06 02052017 19:0610

    Thinking about medicine

    Surviving life on the wards

    The ward round

    ¡¤ All entries on the patient record must have: date, time, the name of the clinician

    leading the interaction, the clinical ? ndings and plan, your signature, printed name,and contact details. Make sure the patient details are at the top of every side of

    paper. Write legibly¡ªthis may save more than the patient.

    ¡¤ A problem list will help you structure your thoughts and guide others.

    ¡¤ BODEX: Blood results, Observations, Drug chart, ECG, X-rays. Look at these. If you

    think there is something of concern, make sure someone else looks at them too.

    ¡¤ Document what information has been given to the patient and relatives.

    Handover

    ¡¤Make sure you know when and where to attend.

    ¡¤Make sure you understand what you need to do and why. ¡®Check blood results¡¯ or

    ¡®Review warning score¡¯ is not enough. Better to: ¡®Check potassium in 4 hours and

    discuss with a senior if it remains >6.0mmolL¡¯ .

    On call

    ¡¤Write it down.

    ¡¤ The ABCDE approach (p779) to a sick patient is never wrong.

    ¡¤ Try and establish the clinical context of tasks you are asked to do. Prioritize and let

    staf know when you are likely to get to them.

    ¡¤ Learn the national early warning score (NEWS) (p892, ? g A1).

    ¡¤ Smile, even when talking by phone. Be polite.

    ¡¤ Eat and drink, preferably with your team.

    Making a referral

    ¡¤ Have the clinical notes, observation chart, drug chart, and investigation results to

    hand. Read them before you call.

    ¡¤ Use SBAR: Situtation (who you are, who the patient is, the reason for the call),Background, Assessment of the patient now, Request.

    ¡¤ Anticipate: urine dip for the nephrologist, PR exam for the gastroenterologist.

    With the going down of the sun we can momentarily cheer ourselves up by the

    thought that we are one day nearer to the end of life on earth¡ªand our respon-

    sibility for the unending tide of illness that ? oods into our corridors, and seeps

    into our wards and consulting rooms. Of course you may have many other quiet

    satisfactions, but if not, read on and wink with us as we hear some fool telling us

    that our aim should be to produce the greatest health and happiness for the great-

    est number. When we hear this, we don¡¯t expect cheering from the tattered ranks

    of on-call doctors; rather, our ears detect a decimated groan, because these men

    and women know that there is something at stake in on-call doctoring far more

    elemental than health or happiness: namely survival.

    Within the ? rst weeks, however brightly your armour shone, it will now be

    smeared and spattered, if not with blood, then with the fallout from the many

    decisions that were taken without sui cient care and attention. Force majeure on

    the part of Nature and the exigencies of ward life have, we are suddenly stunned

    to realize, taught us to be second-rate; for to insist on being ? rst-rate in all areas

    is to sign a death warrant for ourselves and our patients. Don¡¯t keep re-polishing

    your armour, for perfectionism does not survive untarnished in our clinical world.

    Rather, to ? ourish, furnish your mind and nourish your body. Regular food makes

    midnight groans less intrusive. Drink plenty: doctors are more likely to be oliguric

    than their patients. And do not voluntarily deny yourself the restorative power of

    sleep, for it is our natural state, in which we were ? rst created, and we only wake

    to feed our dreams.

    We cannot prepare you for ? nding out that you are not at ease with the person

    you are becoming, and neither would we dream of imposing a speci? c regimen of

    exercise, diet, and mental ? tness. Finding out what can lead you through adversity

    is the ar ......